Innovative Mobile Technologies improving health in developing countries. Professor Kristin Braa Department of Informatics University of Oslo

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1 Innovative Mobile Technologies improving health in developing countries Professor Kristin Braa Department of Informatics University of Oslo

2 The importance of mobile technology for developing countries There are 4,5 billion mobile phones 305 millions PC s, but only 11 million hospital beds The mobile is the Internet device

3 The importance of the mobile phone to developing countries % Mobile subs Households with PC 79 mobile subscriptions per 100 inhabitants 25 PCs per 100 households Diffusion of Mobiles and PCs in Developing Countries as of 2011 Data from the International Telecommunication Union (ITU) 3

4 Mobile subs per 100 inhabitants (2012) Case: India Mobiles exploding, few PCs 929 milling mobile subs in May 2012 (78%) 142 million sub added in million PCs in use (2009) 4,7 PCs per 100 inhabitants ,2 fixed Internet connections per 100 households (2011) 121 million Internet users (2011) 11%, 97 million are active (at least once in a month) Internet usage penetration growth is only 19% Broadband penetration 0,014% Data from the International Telecommunication Union (ITU) Telecom Regulator of India (TRAI) Boston Consulting Group Internet & Mobile Association of India 4

5 Health Information Systems Program - DHIS2 HISP is a global action research network headed and initiated at the Dept. of Informatics, University of Oslo since 1994 DHIS 2 is an open source software developed, customized and used for reporting, analysis and dissemination of health data for many health programs Shared and integrated data warehouse for essential health data: information for action Implemented in 30 countries, national standard in 12 countries, WHO endorsed Joint 3-donor (PEPFAR, Global Fund, Norad) effort to strengthen DHIS 2 use in countries UiO Innovation award 2013

6 United Nations Millenium Development Goal indicators (2000) MDG 4 Underweight rate of children under 5 Under 5, Infant Mortality Rate, Under 1 year measles immunisation coverage MDG5 Births attended by skilled midwives Maternal Mortality Ratio MDG6 HIV (15-24 years) in ANC, Malaria, TB prevalence, death and cure rates

7 DHIS 2 as an online national HIS - integrated repository for all health statistics

8 Action oriented multidisciplinary research Strengthening national health information systems Collaborating with Ministries of Health Building capacity locally At present 32 PhD students worldwide. 20 graduated PhD school 5 international Masters program DHIS Academy (East Africa, West Africa, Asia, Latin America) Research theme: Implementation Interoperability Architect(ing) Scaling Open source software development done in a global network

9 DHIS 2 Academy: Regional training program in East Africa, West Africa, Asia, Latin-America Advanced DHIS 2 Academy, Entebbe, 4-13 June 2013

10 EAC Regional Deployment ECOWAS Regional Deployment Present in over 30 countries, 10 Indian states National standard in Kenya, Ghana, Uganda, Rwanda, Liberia, Nigeria, Sierra Leone, Gambia, Zanzibar, Malawi, Zimbawe = National HIS deployment = National start-up / pilot = early national initiative or program-specific deployment

11 Extending the DHIS reach through mobiles Districts / Hospitals Clinics Community Health Workers Community / Villages SMS Java Browser Android PC/laptop/tablet

12 A suit of mobile applications for different available infrastructure Voice calls SMS (sent directly from the user) Java client with SMS or data Mobile browser (native/operamini) Smartphone browser or app Tablets browser or app PCs with web browser & mobile data

13 Low resource constraints Sometimes no power, no roads Expensive to buy good phones Low end phones: cheap, simple, small screens and limited usability Leverage installed base of users phones? Increases complexity: multiple operators, more handsets, more training, private subscriptions

14 Annual measles coverage % Web Portal Data from Mobile devises Data warehouse DHIS 2 -Data mart -Meta data -Visualising tools Dashboard Measles under 1 year coverage by district 2006 (Measles doses given to children < 1 year / total population < 1 year) Chake Michew eni Mkoani Wete Central North A North B South Urban West Chake District District District District District District District District District District Pemba Zone Unguja Zone LMIS Graphs District HR EMR Mobile Maps Getting data in - Data warehousing Getting data out - Decision support systems

15 Learning through network of action Kenya National online HIS using mobile internet Facility census SARA PEPFAR reporting Ghana Fast moving learning from Kenya Limited resources Uganda Maternal and neonatal death audits Tracking of pregnant women SMS reporting on emtct ARV ordering Punjab Mobile HIS reporting, 6000 health workers Zambia 600 mobiles for malaria incidence reporting

16 Developing countries low-tech: Kenya Cloud based services Country wide implementation Mobile broadband Webbased Cloud-based secure, fast deployment and easy to maintain Web-based flexible updating of the service HTML5 with offline-support PC with mobile broadband Support for mobile phones Integrated messaging system connecting the users Sharing of advanced reports and analysis with GIS support

17 Offline support Network coverage variability/instability requires offline capabilities When there is no coverage store locally and submit later Unstable network Server

18 Java-based mobile reporting in India Punjab 6000 Auxiliary Nurse Midwives (ANMs) reporting weekly and monthly using the DHIS-Mobile Java client SMS used as transport. Forms can be stored locally. State has purchased phones and pays for subscriptions. DHIS2 is the state-wide national Health Information System. Paper based reporting still happens and feeds into DHIS2.

19 Uganda Saving Mothers Giving Life Project in 4 districts in Uganda National DHIS2-based infrastructure is used for reporting most routine data from clinics SMS reporting by Village Health Teams (CHWs) National DHIS Database SMS Broadcast Messages

20 SMS Broadcast to Village Health Teams and Beneficiaries From SMGL: Dear VHT member, Encourage all pregnant mothers to attend antenatal care at least four time during pregnancy

21 Weekly reporting Send to 6767 Dashboard Graphs Mobile Maps

22 Results

23 Results

24 Uganda: emtct - SMS Weekly Reporting Goal: Elimination of mother to child transmition of HIV Rolling out to 2,400 Option B+ implementing service outlets pmtct a.400. b.359. c.50. d.98. e.10. f.50. g.0. h.n. i.y

25 Uganda Mother/Child tracking Integrated service for tracking mothers and children through pregancy-delivery-postnatal 10 facilities. PC, Tablets, Smart- and feature phones, SMS Key challenges: Mothers access many clinics. Data is lost. Unclear responsibility for follow-up Fitting a common system into multiple clinic contexts, sizes and workflows Integrating community health workers into electronic system for follow-up, using SMS How to best remind mothers of appointments (SMS) Maintaining privacy of data while sharing DHIS Tracker is used to implement the project

26 Find Person, Enroll and Add Relationship

27 DHIS on smartphones with offline support

28 Leverage on the social network

29 Mobile = communicate and share The mobile is primarily a communication tool! Don t forget to improve communication, even if it is the secondary goal of a specific mhealth project Community features help create sustainability Example: Closed User Group makes people positive about project and acts as an attractor

30 Improving data quality through social media Interpretations Charts, reports, maps can be shared with other users of DHIS 2 Discussion forum open to all users to comment on the data Fostering communities of data use

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33 Research agenda: Pilot to scale Pilots Early decisions of solution type create path dependencies

34 Principles for pilot to scale Leverage existing systems think national Work with the Ministries of Health Put servers online, but think offline Think scale already in the pilot phase Support a range of mobile devices Do not get locked in to one mobile operator Use local resources to drive implementation Work with partners a network of action Share the collected information!!

35 HISP collaborative Network of Action Health Information Systems Research, Implementation Development Open Source Software DHIS2 Sharing across the world Regional development West Africa & East Africa: Botswana Norway Vietnam South Africa Malawi Togo others Nigeria Liberia Sri Lanka Mali Tanzania Burkina Faso Ghana Bangladesh Uganda Kenya Rwanda India Gambia Sierra Leone Côte d Ivoir Capacity Building Training, Education, Research Partner contribution PSI, Pepfar, Global Fund Use of DHIS for own reporting & development

36 High tech low resource big impact

37 Thank you